2. CMAST 2
IntroductionIntroduction
Review methods of hemorrhage control inReview methods of hemorrhage control in
a tactical environment.a tactical environment.
Hemorrhage is the leading cause ofHemorrhage is the leading cause of
preventable death on the battlefield.preventable death on the battlefield.
Hemorrhage control save lives.Hemorrhage control save lives.
New Hemostatic agents available.New Hemostatic agents available.
6. CMAST 6
BloodBlood
Adult body:Adult body:
– Contains approximately 5 to 6 liters of bloodContains approximately 5 to 6 liters of blood
– Loss of 1 pint of blood without harmful effectsLoss of 1 pint of blood without harmful effects
– Loss of 2 pints may cause shockLoss of 2 pints may cause shock
Three phases ofThree phases of
hemostasis:hemostasis:
– Vascular spasmVascular spasm
– Platelet plug formationPlatelet plug formation
– Blood clottingBlood clotting
(coagulation cascade)(coagulation cascade)
7. CMAST 7
HemorrhageHemorrhage
Pulse vs. Blood Pressure.Pulse vs. Blood Pressure.
How long until there are changes?How long until there are changes?
Young healthy adults compensate for longYoung healthy adults compensate for long
periods, then decompensate rapidly.periods, then decompensate rapidly.
At what blood pressure do casualties loseAt what blood pressure do casualties lose
consciousness?consciousness?
─ @ 50 mm Hg@ 50 mm Hg
8. CMAST 8
Clinical Signs of Acute HemorrhageClinical Signs of Acute Hemorrhage
ClassClass % Blood% Blood
LossLoss
Clinical SignsClinical Signs
II Up to 750 mlUp to 750 ml
(15%)(15%)
Slight increase in HR; no change in BPSlight increase in HR; no change in BP
or respirationsor respirations
IIII 750-1500 ml750-1500 ml
(15-30%)(15-30%)
Increased HR and respirations;Increased HR and respirations;
increased diastolic BP; anxiety, fright orincreased diastolic BP; anxiety, fright or
hostilityhostility
IIIIII 1500-20001500-2000
ml (30-40%)ml (30-40%)
Increased HR and respirations; fall inIncreased HR and respirations; fall in
systolic BP; significantsystolic BP; significant AMSAMS
IVIV >2000>2000
(>40%)(>40%)
Severe tachycardia; severe lowering ofSevere tachycardia; severe lowering of
BP; cold, pale skin; severe AMSBP; cold, pale skin; severe AMS
9. CMAST 9
Sources of HemorrhageSources of Hemorrhage
External:External:
– Visible blood is hard to estimateVisible blood is hard to estimate
Internal:Internal:
– May be hidden within the torso or even inMay be hidden within the torso or even in
the extremities secondary to fracturesthe extremities secondary to fractures
10. CMAST 10
Sources of External BleedingSources of External Bleeding
Arterial:Arterial:
─Rapid, profuse and pulsatingRapid, profuse and pulsating
─Bright red in colorBright red in color
Venous:Venous:
─Steady flowSteady flow
─Dark red or maroon in colorDark red or maroon in color
Capillary:Capillary:
─Slow and oozingSlow and oozing
─Often clots spontaneouslyOften clots spontaneously
14. CMAST 14
Hemorrhage ControlHemorrhage Control
Assess the tactical situation.Assess the tactical situation.
Expose the wound.Expose the wound.
Attempt to control theAttempt to control the
bleeding with directbleeding with direct
pressure or a pressurepressure or a pressure
dressing.dressing.
17. CMAST 17
Hemorrhage ControlHemorrhage Control
Life-threatening arterial bleedingLife-threatening arterial bleeding
(amputation) may require early use of a(amputation) may require early use of a
tourniquet.tourniquet.
If under enemy fire or in a dangerousIf under enemy fire or in a dangerous
position rapidly apply a tourniquet andposition rapidly apply a tourniquet and
move casualty to cover.move casualty to cover.
18. CMAST 18
TourniquetsTourniquets
Several new tourniquets have beenSeveral new tourniquets have been
selected as primary means to controlselected as primary means to control
hemorrhage in combat.hemorrhage in combat.
19. CMAST 19
Combat Application TourniquetCombat Application Tourniquet
WINDLASS
SELF ADHERING BAND
WINDLASS STRAP
The C-A-T was selected as the primary tourniquetThe C-A-T was selected as the primary tourniquet
for every soldier.for every soldier.
20. C-A-T Step 1C-A-T Step 1
Place the
wounded
extremity
through the loop
of the Self-
adhering Band
29. C-A-T TourniquetC-A-T Tourniquet
NOTE:
The friction adaptor
buckle is not
necessary for
proper C-A-T
application to an
arm. It MUST be
used with two
hands when
applying to a leg.
30. C-A-T: Lower ExtremityC-A-T: Lower Extremity
To use, wrap
the Self-
adhering Band
through the
friction
adaptor
buckle.
31. C-A-T: Lower ExtremityC-A-T: Lower Extremity
This prevents
the Self-
adhering Band
from loosening
during
transport.
35. CMAST 35
SOFTT ApplicationSOFTT Application
Similar to the CAT:Similar to the CAT:
─ Slide loop over extremitySlide loop over extremity
─ Pull strap tightPull strap tight
─ Twist windlass untilTwist windlass until
bleeding stopsbleeding stops
─ Latch the windlassLatch the windlass
with one of thewith one of the
tri-ringstri-rings
─ Tighten the safetyTighten the safety
screwscrew
37. CMAST 37
Improvised TourniquetImprovised Tourniquet
Place cravat between heart and wound.Place cravat between heart and wound.
Tie a half-knot on upper surface.Tie a half-knot on upper surface.
Place a short stick on half-knot.Place a short stick on half-knot.
Tie a square knot on top ofTie a square knot on top of
stick.stick.
Twist stick (windlass) toTwist stick (windlass) to
tighten.tighten.
UNTIL BLEEDING STOPS.UNTIL BLEEDING STOPS.
Secure windlass to prevent unwinding.Secure windlass to prevent unwinding.
39. CMAST 39
Tourniquet PrinciplesTourniquet Principles
Never cover a tourniquet.Never cover a tourniquet.
Mark a “T” on the casualty's forehead orMark a “T” on the casualty's forehead or
somewhere obvious (sharpie pen).somewhere obvious (sharpie pen).
In combat when the tactical situationIn combat when the tactical situation
allows, loosening a tourniquet isallows, loosening a tourniquet is
appropriate.appropriate.
40. CMAST 40
Tourniquet RemovalTourniquet Removal
Once the tactical situation allows,Once the tactical situation allows,
tourniquets should be loosened and othertourniquets should be loosened and other
methods to stop bleeding applied.methods to stop bleeding applied.
─Direct pressure - pressure dressingDirect pressure - pressure dressing
─HemCon Chitosan BandageHemCon Chitosan Bandage
─QuikClot powderQuikClot powder
41. CMAST 41
Tourniquet RemovalTourniquet Removal
When loosening a tourniquet, do notWhen loosening a tourniquet, do not
remove it from the limb.remove it from the limb.
If the tourniquet has been in place forIf the tourniquet has been in place for
> 6 hours, do not remove.> 6 hours, do not remove.
If fluid resuscitation is required, it shouldIf fluid resuscitation is required, it should
be accomplished before the tourniquetbe accomplished before the tourniquet
is removed.is removed.
Tourniquets are very painful, provideTourniquets are very painful, provide
pain medications as needed.pain medications as needed.
42. CMAST 42
Tourniquet RemovalTourniquet Removal
If tourniquet has been in place for onlyIf tourniquet has been in place for only
1-2 hours, loosening and using other1-2 hours, loosening and using other
methods to control hemorrhage canmethods to control hemorrhage can
salvage limbs.salvage limbs.
Remember: if unable to controlRemember: if unable to control
hemorrhage by other means, re-tightenhemorrhage by other means, re-tighten
the tourniquet.the tourniquet.
It is better to sacrifice the limb than toIt is better to sacrifice the limb than to
lose a life to hemorrhage.lose a life to hemorrhage.
43. CMAST 43
AmputationAmputation
Apply a pressure dressing to cover theApply a pressure dressing to cover the
end of the stump.end of the stump.
Kerlix and 6” Ace wrap for effectiveKerlix and 6” Ace wrap for effective
pressure dressing.pressure dressing.
Rinse amputated part free of debris.Rinse amputated part free of debris.
Wrap loosely in saline-moistened sterileWrap loosely in saline-moistened sterile
gauze.gauze.
44. CMAST 44
Preservation of Amputation PartsPreservation of Amputation Parts
Seal amputated part in a plastic bag orSeal amputated part in a plastic bag or
cravat.cravat.
Place in a cool container; do not allow toPlace in a cool container; do not allow to
freeze.freeze.
Never place an amputated part in water.Never place an amputated part in water.
Never place amputated part directly on ice.Never place amputated part directly on ice.
Never use dry ice to cool an amputatedNever use dry ice to cool an amputated
part.part.
46. CMAST 46
Chitosan Hemostatic DressingChitosan Hemostatic Dressing
Hold the foil over-pouch so that instructions canHold the foil over-pouch so that instructions can
be read. Identify unsealed edges at the top of thebe read. Identify unsealed edges at the top of the
over-pouch.over-pouch.
47. CMAST 47
Chitosan Hemostatic DressingChitosan Hemostatic Dressing
Peel open over-pouch by pulling the unsealedPeel open over-pouch by pulling the unsealed
edges apart.edges apart.
48. CMAST 48
Chitosan Hemostatic DressingChitosan Hemostatic Dressing
Trap dressing between bottom foil and non-Trap dressing between bottom foil and non-
absorbable green/black polyester backing withabsorbable green/black polyester backing with
your hand and thumb.your hand and thumb.
49. CMAST 49
Chitosan Hemostatic DressingChitosan Hemostatic Dressing
Hold dressing by the non-absorbable polyester backingHold dressing by the non-absorbable polyester backing
and discard the foil over-pouch. Hands must be dry toand discard the foil over-pouch. Hands must be dry to
prevent dressing from sticking to them.prevent dressing from sticking to them.
51. CMAST 51
Chitosan Hemostatic DressingChitosan Hemostatic Dressing
Place the light colored sponge portion of thePlace the light colored sponge portion of the
dressing directly to the wound area with thedressing directly to the wound area with the
most severe bleeding. Apply pressure for 2most severe bleeding. Apply pressure for 2
minutes or until the dressing adheres andminutes or until the dressing adheres and
bleeding stops. Once applied and in contactbleeding stops. Once applied and in contact
with the blood and other fluids, the dressingwith the blood and other fluids, the dressing
cannot be repositioned.cannot be repositioned.
A new dressing should be applied to otherA new dressing should be applied to other
exposed bleeding sites; each new dressingexposed bleeding sites; each new dressing
must be in contact with tissue where bleedingmust be in contact with tissue where bleeding
is heaviest. Care must be taken to avoidis heaviest. Care must be taken to avoid
contact with the casualty’s eyes.contact with the casualty’s eyes.
52. CMAST 52
Chitosan Hemostatic DressingChitosan Hemostatic Dressing
If dressing is not effective in stoppingIf dressing is not effective in stopping
bleeding after 4 minutes, remove the originalbleeding after 4 minutes, remove the original
and apply a new dressing. Additionaland apply a new dressing. Additional
dressings cannot be applied over ineffectivedressings cannot be applied over ineffective
dressings.dressings.
Apply a battle dressing/bandage to secure aApply a battle dressing/bandage to secure a
hemostatic dressing in place.hemostatic dressing in place.
Hemostatic dressings should only beHemostatic dressings should only be
removed by responsible persons afterremoved by responsible persons after
evacuation to the next level of care.evacuation to the next level of care.
56. CMAST 56
QuikClotQuikClot
Warning: Avoid contact with wet skin;Warning: Avoid contact with wet skin;
product reacts with small amounts ofproduct reacts with small amounts of
water and can cause burning.water and can cause burning.
Stop burning by brushing away granulesStop burning by brushing away granules
and flooding area with large volume ofand flooding area with large volume of
water.water.
If ingested, immediately drink two or moreIf ingested, immediately drink two or more
glasses of water.glasses of water.
57. CMAST 57
QuikClotQuikClot
Directions:Directions:
1-Apply direct firm pressure to wound using sterile1-Apply direct firm pressure to wound using sterile
dressing or best available substitutedressing or best available substitute
2-If bleeding is stopped or nearly stopped after2-If bleeding is stopped or nearly stopped after
approximately 1 minute of pressure, wrap and tieapproximately 1 minute of pressure, wrap and tie
bandage to maintain pressure on woundbandage to maintain pressure on wound
3-If moderate to severe bleeding continues, hold3-If moderate to severe bleeding continues, hold
pack away from face and tear open at tabspack away from face and tear open at tabs
58. CMAST 58
QuikClotQuikClot
4-Use wiping motion to remove gauze and4-Use wiping motion to remove gauze and
excess blood – immediately start a slowexcess blood – immediately start a slow
pouring of one QuikClot packet directly ontopouring of one QuikClot packet directly onto
the wound. Stop pouring as soon as drythe wound. Stop pouring as soon as dry
granules cover the wound areagranules cover the wound area
5-Use only enough QuikClot to stop bleeding. If5-Use only enough QuikClot to stop bleeding. If
bleeding continues open a second packet ofbleeding continues open a second packet of
QuikClot and continue to use as directedQuikClot and continue to use as directed
59. CMAST 59
QuikClotQuikClot
6-Reapply firm pressure to QuikClot covered6-Reapply firm pressure to QuikClot covered
wound using sterile gauze. Wrap and tiewound using sterile gauze. Wrap and tie
bandage to maintain pressurebandage to maintain pressure
61. CMAST 61
Treatment GoalsTreatment Goals
Hemorrhage control continues to be theHemorrhage control continues to be the
priority in battlefield care.priority in battlefield care.
Hemorrhage is the leading cause ofHemorrhage is the leading cause of
preventable death on the battlefield.preventable death on the battlefield.
Our focus must be on stopping soldiersOur focus must be on stopping soldiers
from bleeding to death on the battlefield.from bleeding to death on the battlefield.
